Arkansas is at the forefront of states that have implemented work requirement policies, doing so in both Medicaid and the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps). Elected officials in Arkansas presented work requirements as a way to help low-income Arkansans achieve self-sufficiency through employment.
Federal courts are considering the legality of Medicaid work requirements, but Urban Institute research on Arkansas’s work requirements in Medicaid and SNAP illustrates that the policies’ design and implementation do not appear to help people achieve self-sufficiency through employment.
Our focus groups with Arkansans reveal confusion about the requirements and how people can prove their compliance. People also face limited availability of high-quality jobs or meaningful education and training opportunities. As a result, they risk losing access to vital health care coverage and nutrition assistance.
How work requirements work
In June 2018, Arkansas became the first state to impose work requirements on beneficiaries of Medicaid expansion, called Arkansas Works. Under the program, failure to complete and report 80 hours of work or “community engagement” (such as volunteering, looking for a job, or attending school) for three months during a calendar year resulted in disenrollment for the remainder of the year.
Arkansas’s Medicaid work requirements led to more than 18,000 people losing Medicaid coverage by December 2018 during its first six months of implementation. The program was halted by a court order in March 2019.
Arkansas also reinstated work-related time limits in SNAP in 2016. This policy requires adults (ages 18–49, without disabilities or dependents) to work or engage in job training to access SNAP for longer than three months in a three-year period. Often the same people who are subject to the SNAP time limits rely on Medicaid for their health care needs.
To find out how these policies played out, Urban Institute researchers conducted focus groups with people who were currently enrolled in Arkansas Works or those who lost coverage because of noncompliance.
We also spoke to people who had participated in SNAP (and who were likely subject to the time-limit rules), as well as state Medicaid, SNAP, and Workforce Services officials, health care providers, SNAP Employment and Training program providers, consumer advocates, health plan representatives, and health and social services policy researchers.
Here’s what we found:
Confusion about requirements
Nearly everyone in our focus groups had heard about work requirements in Medicaid and SNAP, but most didn’t understand the requirements, believed they didn’t apply to them, or were confused about how to report that they were meeting the requirements.
The Arkansas Department of Human Services (DHS) did extensive outreach before implementing Medicaid work requirements through letters, phone calls, and social media, but the message was not reaching the target audience, and many who received messages found them complex and confusing. Medicaid also relied primarily on an online reporting system that was poorly designed, presented accessibility challenges, and caused lots of frustration.
Similarly, SNAP participants in our focus groups were unclear about which activities, outside of employment, counted toward the 80-hour-per-month requirement and how many hours of each activity counted toward the requirement. The difficulty of seeking information from DHS or other service providers about complying with the SNAP work requirement left them feeling frustrated and disempowered.
By the time I got the letter, I only had one day to [report my hours], and I tried to get online to do it, and it wouldn’t let me. So, I don’t even know if I have [health insurance] right now.
Limited investment in work supports
If states want to promote sustained employment among participants in safety net programs, they need infrastructure to help people access higher-quality jobs.
Arkansans subject to work requirements face many challenges to obtaining and maintaining employment, including low educational attainment and literacy rates, health problems, limited transportation and child care, poor internet access, criminal records, and residence in high-unemployment or high-poverty neighborhoods.
To promote access to employment, the Arkansas Department of Workforce Services runs 10 comprehensive workforce centers throughout the state and 27 satellite centers. Thirty-three SNAP employment and training program providers serve the state’s 75 counties, and these providers partner with others.
But in practice, the education and training opportunities available to people subject to work requirements are often limited to soft-skills training and basic work-readiness activities, such as résumé preparation, mock interviews, and learning about professionalism. Although these services are vital to some participants, many need greater support, such as technical skill training, to land a job or advance their career.
Consequently, the hours people spend in activities to comply with the requirement may not be moving them toward self-sufficiency. For example, a focus group participant who couldn’t access more advanced computer training sat through a basic skills training that covered topics she already knew. She said, “You take what they tell you to take.”
I live in Pine Bluff and… there aren’t really too many job opportunities down there. I go and fill out [job applications], but there aren’t many things I can fill out for.
Implications of losing nutrition benefits and health insurance
Sometimes people don’t discover that they’ve lost access to vital supports until they are in the checkout line at the grocery store, seeking care in a doctor’s office or hospital, or picking up a prescription at a pharmacy. Losing access to nutrition assistance, even temporarily, disrupts already tight budgets and forces people to choose between necessities.
Focus group participants who lost Medicaid coverage said it affected their ability to obtain needed medical care and prescription drugs. Health care providers, hospitals, and Medicaid health plans also expressed concern over decreases in coverage and increases in “self-pay” and charity care (i.e., uninsured) patients for whom they will not be compensated.
I went to pick up my prescription, and they said I couldn’t get it…. It was a big shock. At first, I was upset, and then I was worried because I need my medicine. I shouldn’t find out the day I need my medicine.
The legality of Medicaid work requirements has yet to be determined by the federal courts, while many states are considering expanded imposition of SNAP work requirements. Yet key informants and focus group participants still identified lessons learned from both the Medicaid and SNAP work requirements in Arkansas that could reduce benefits loss and promote people’s ability to work, including the following:
- expanding the scope, depth, and intensity of state and community-based outreach and education efforts
- simplifying and expanding the process for reporting work and community engagement activities
- increasing funding of work support agencies and infrastructure so that they have the employment and training capacity to help people gain employment
But many people we interviewed believed that, even if these solutions were implemented, program participants would likely still face barriers to compliance, and the limited availability of high-quality jobs could pose a formidable obstacle to work.
Though many Medicaid and SNAP participants (and service providers and policymakers) agree with the idea that people capable of working should do so, they question the value of work requirements in light of the real-life experiences of people subject to them. Their experiences illustrate the challenges of compliance, which often result in losing access to vital health care coverage and nutrition assistance.
Work requirement experiences in Arkansas provide a cautionary tale for other states considering implementing work requirements for safety net programs.